472 Accuracy of Documentation and Handover of Surgical Operation Details in Cardiac Surgery

Introduction

GMC Good Medical Practice Guideline states that documentation must be clear, accurate and legible. Accurate documentation of operation notes ensures proper postoperative care and forms important legal documents. This audit aims to assess the accurateness and consistency of recorded operation names throughout patients’ hospital stay following cardiac surgery, as well as the effect of standardisation of operation names to improve the accuracy of documentation.

Method

Patients undergoing cardiac surgery at St. Bartholomew's Hospital from November 29 to December 10, 2021, had data prospectively collected from their electronic patient records, which were compared to the standardised operation name. After the first audit cycle, junior medical staff were educated on the standardisation of operation names. Electronic patient records were reviewed again for patients undergoing cardiac surgery from January 10 to January 20, 2022.

Results

Following intervention, there were significant improvements in the accuracy of documented operation details. Initially, 65% of operation notes were accurately documented, whereas 96% of operation notes were completed to the ideal standard post-intervention. There was a 37% increase in the number of accurate discharge summaries, while inaccuracies and missing operation names were reduced to 0% from the initial 12%.

Conclusions

Accurate documentation of operation details is expected by GMC standards. Poor documentation can hinder the quality-of-care patients receive postoperatively. We have shown variation in descriptions of standard operations and multiple inaccuracies throughout patients’ hospital stay. We suggest agreed standardisation of operation details and education of junior medical staff regarding accuracy of documentation to enhance compliance with the GMC standard.

Uniparental disomy as a mechanism for X-linked chondrodysplasia punctata

We describe a female infant with X-linked chondrodysplasia punctata (CDPX1) as a result of maternal isodisomy of the X chromosome. Targeted Sanger sequencing and targeted next-generation sequencing of ARSL were used to test for the familial variant. This patient was homozygous for ARSL NM_000047.2: c.1227_1228delinsAT p.(Ser410Cys) familial variant, consistent with a diagnosis of CDPX1. Uniparental disomy is a type of chromosomal variation. Although not necessarily pathogenic, it can cause imprinting disorders and X-linked recessive disorders in females, and be a cause of autosomal recessive conditions when only one parent is a carrier. The patient described highlights that uniparental disomy can be a rare cause of X-linked recessive conditions. This mode of inheritance has not been previously described in this condition.

AB0584 MANAGEMENT OF REFERRALS, TREATMENT STRATEGY, AND RESEARCH CHALLENGES IN POLYMYALGIA RHEUMATICA AMONGST RHEUMATOLOGISTS WORLDWIDE: A QUESTIONNAIRE BASED STUDY

Background

Polymyalgia rheumatica (PMR) is diagnosed and treated by both general practitioners (GP) and rheumatologists. How rheumatologists around the world manage the referral process of patients with PMR from GP’s has not been described. EULAR/ACR guidelines recommend initial prednisolone doses between 12.5 and 25 mg, but it is unknown if guidelines are followed in daily clinical practice1. In addition, the understanding of challenges for recruitment to clinical trials in PMR is currently limited.

Objectives

This study aims to describe the management of referrals, treatment strategy, and recruitment to clinical trials in PMR among rheumatologists worldwide.

Methods

An English language questionnaire was drafted by a working group of rheumatologists and GP’s from 6 different countries. Questions concerned: 1: respondent, 2: referrals, 3: prednisolone, and 4: barriers to research. Questionnaires were distributed to rheumatologists via members of the International PMR/GCA study group. Answers were collected via an online survey tool (Redcap), from 2nd of November 2021 to 27th of January 2022. Countries were grouped by income and geographical region based on the World bank classifications. Data were weighted by number of inhabitants in a country, based on the United Nations age specific population count, divided by number of respondents in a country. Countries with more than 20 respondents were included.

Results

Results from 27 countries were analysed including 1000 responders in total (Figure 1). There was large variation in time from referral to first assessment, initial dose of prednisolone was high, duration of treatment was relatively short, and a large proportion of patients with newly diagnosed PMR received prednisolone prior to rheumatological evaluation (Table 1). Concerning the 15% of respondents who performed research in PMR, 52% had participated in clinical trials and 56% of the responders experienced difficulties with recruitment.

Table 1.

Characteristics of reponders, referrals, and treatment.

Geographical regionIncomeThe worldEurope and Central AsiaNorth AmericaLatin AmericaEast Asia and PacificSouth AsiaMiddle East and AfricaHigh- income countriesLow- and middle- income countriesRespondersResponders (n), Completed questionnaire (total)875 (1000)294 (304)78 (81)136 (152)53 (53)53 (72)261 (338)446 (458)429 (542)Experience as rheumatologist (years)11 (6-20)12 (6-20)7 (4-20)11 (6-23)21 (10-30)7 (4-10)9 (5-18)11 (5-22)8 (5-12)ReferralsGP’s can discuss patients prior to referral, %647979575860677461Referred patients seen (%)100 (90-100)100 (90-100)100 (100-100)100 (100-100)100 (95-100)100 (100-100)100 (60-100)100 (100-100)100 (90-100)Evaluation > 2 weeks after referral, %26498060216185815PrednisoloneStarted prior to rheumatological evaluation (%)50 (20-50)60 (30-80)70 (50-80)50 (10-50)30 (20-50)50 (20-80)20 (0-50)50 (30-80)50 (10-70)Initial dose (mg)20 (15-40)20 (15-20)20 (15-20)20 (20-40)15 (15-15)20 (15-40)20 (15-40)15 (15-20)20 (15-40)Initial dose > 25 mg, %32964104143642Duration of treatment (months)12 (6-12)12 (12-18)12 (10-18)6 (3-12)18 (12-18)12 (6-12)6 (3-12)12 (12-18)9 (6-12)

Data presented as weighted median (interquartile range) unless otherwise stated.

GP: general practitioner

Conclusion

This is the first description of current practice in managing referrals and treatment of PMR by rheumatologists worldwide. In general, median treatment duration was according to EULAR/ACR guidelines, but initial dose of prednisolone was often higher than recommended in many parts of the world. PMR patients were often seen more than two weeks after referral, and treatment had started prior to first rheumatological evaluation.

References

[1]Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Annals of the rheumatic diseases 2015; 74(10): 1799-807.

Acknowledgements

This study was endorsed by the international PMR/GCA study group.

Disclosure of Interests

Agnete Overgaard Donskov: None declared, Sarah Mackie: None declared, Ellen-Margrethe Hauge Speakers bureau: AbbVie, Sanofi, Sobi, MSD, UCB, Consultant of: AbbVie, Sanofi, Sobi, MSD, UCB, Grant/research support from: Novo Nordic Foundation, Danish Rheumatism Association, Danish Regions Medicine Grants, Roche, Novartis, Celgene, MSD, Pfizer, Roche, Sobi, CARLOS TORO GUTIÉRREZ: None declared, Ib Hansen: None declared, Andrea Hemmig: None declared, Aatke van der Maas: None declared, Tamer A Gheita: None declared, Berit Dalsgaard NIelsen Paid instructor for: Roche, Karen Douglas: None declared, Richard Conway Speakers bureau: Janssen, Roche, Sanofi, Abbvie,, Elena Rezus: None declared, Bhaskar Dasgupta: None declared, Sara Monti: None declared, Eric Matteson Consultant of: Boehringer-Ingelheim,, Grant/research support from: Boehringer Ingelheim,, Sebastian E. Sattui Grant/research support from: AstraZeneca, Mark Matza: None declared, Vanessa Ocampo Speakers bureau: Abbvie, Andrea Bran: None declared, Simone Appenzeller Grant/research support from: GSK, Annelise Goecke Speakers bureau: Abbvie, Boehringer Ingelheim, Recalcine. Consultant Abbvie, Boehringer Ingelheim, NELLY COLMAN MC LEOD Speakers bureau: Laboratorios FAPASA (Farmacéutica Paraguay), Helen Keen Speakers bureau: Roche, Abbvie, Masataka Kuwana: None declared, Latika Gupta: None declared, Babur Salim: None declared, Ghita Harifi Speakers bureau: Abvie, Johnson and johnson, Lilly, Novartis, Mariama Erraoui: None declared, Nelly Ziade Speakers bureau: Abbvie, Eli Lilly, Janssen, Pfizer, Pierre Fabre, Roche, Novartis, Sanofi-Aventis, Paid instructor for: Abbvie, Eli Lilly, Sanofi-Aventis, Pfizer, Janssen, Novartis., Consultant of: Abbvie, Eli Lilly, Janssen, Pfizer, Roche, Novartis, Sandoz, Grant/research support from: Abbvie, Celgene - Algorithm, Bristol-Myers Squibb - NewBridge, Pfizer, Nizar Abdulateef Al-Ani: None declared, Adeola Ajibade: None declared, Johannes Knitza: None declared, Line Frølund: None declared, Max Yates: None declared, Victor Pimentel-Quiroz: None declared, Andre Lyrio: None declared, Maria Sandovici: None declared, Kornelis van der Geest Speakers bureau: Roche, Toby Helliwell Grant/research support from: Valneva, Elisabeth Brouwer Speakers bureau: Roche, Christian Dejaco Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, Consultant of: Abbvie, Eli Lilly, Janssen, Roche, Galapagos and Sanofi, Kresten Keller: None declared

AB0583 REFERRAL PATTERN AND TREATMENT OF POLYMYALGIA RHEUMATICA IN GENERAL PRACTICE: AN INTERNATIONAL QUESTIONNAIRE BASED STUDY

Background

In most countries polymyalgia rheumatica (PMR) is diagnosed and managed by both general practitioners (GP) and rheumatologists. However, the referral pattern from GP’s to specialist around the world has not been described. The initial prednisolone dose recommended by EULAR/ACR is between 12.5 and 25 mg1, but little is known about whether these guidelines are followed everywhere by GP’s in clinical practice2.

Objectives

This study aims to describe the refererral pattern and treatment strategy for PMR in general practice in several countries worldwide.

Methods

An English language questionnaire was drafted by a working group of rheumatologists and GP’s from 6 different countries. The questionnaire contained questions on: 1: Respondent, 2: Referral pattern and 3: Prednisolone. Questionnaires were distributed to GP’s via members of the International PMR/GCA study group. Answers were collected via an online survey tool (Redcap), from 3rd of November 2021 to 27th of January 2022. Countries with more than 15 responders to the questionnaire were included in the analysis.

Results

Data from 11 countries were analysed. Referral patterns differed widely among countries (Table 1). Almost all patients initially seen by rheumatologists were returned to GP’s for treatment. In all countries a proportion of the GP’s prescribed higher initial prednisolone doses than recommended, with a large variation between countries (Table 1).

Table 1.

Characteristics of responders, referral pattern, and treatment strategy

AustriaCanadaColombiaDenmarkItalyNether-landsNew ZealandRomaniaRussiaSwitzer-landUnited KingdomRespondersResponders (n), Completed questionnaire (total)26 (29)15 (15)17 (23)53 (53)36 (41)22 (22)17 (17)37 (43)42 (49)26 (26)34 (35)Experience (years)20 (12-34)8 (4-10)6 (4-9)12 (10-17)15 (5-27)23 (17-30)14 (9-27)21 (16-30)6 (5-9)26 (15-32)16 (11-24)Available PMR/GCA guideline, n (%)26 (100)15(100)17 (100)53 (100)36 (100)22 (100)17 (100)37 (100)42 (100)26 (100)34 (100)Adherence to guideline, n (%)21 (82)15 (100)17 (100)51 (97)34 (94)21 (95)17 (100)37 (100)42 (100)26 (100)34 (100)ReferralsNew PMR patients referred for diagnose (%)58 (10-100)50 (2-100)100 (13-100)50-(20-100)60 (28-100)20 (10-50)10 (10-20)60 (10-88)1 (1-2)28 (10-50)10 (1-25)Patients returned to GP for treatment (%)100 (50-100)50 (2-100)8 (0-50)85 (40-100)50 (0-100)50 (10-90)100 (90-100)80 (50-98)1 (1-1)80 (10-100)100 (100-100)Patients referred during treatment (%)50 (25-90)50 (10-100)100 (50-100)20 (10-33)50 (15-80)15 (10-30)20 (10-25)30 (10-80)1(1-1)20 (10-30)10 (10-20)PrednisoloneInitial dose (mg)38 (25-50)20 (20-50)20 (10-30)25 (15-40)25 (25-25)15 (15-15)20 (15-40)15 (12-20)15 (15-15)50 (25-50)15 (15-20)Initial dose > 25 mg, n (%)12 (47)4 (25)7 (40)14 (26)9 (25)1 (5)6 (38)7 (20)3 (8)22 (83)3 (9)Duration of treatment (months)9 (6-12)6 (2-9)6 (4-24)12 (8-18)5 (3-12)11 (6-12)12 (10-18)2 (2-5)6 (6-6)12 (12-14)15 (12-24)

Data are presented as weighted median (interquartile range) unless otherwise stated. GP: general practitioner, PMR: polymyalgia rheumatica, GCA: great cell arteritis.

Conclusion

Although many patients were referred to the hospital for initial PMR diagnosis or during the disease course, a large proportion of patients received treatment in general practice worldwide. GPs frequently use a higher starting dose of prednisolone and shorter treatment duration than recommended by EULAR/ACR.

References

[1]Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Annals of the rheumatic diseases 2015; 74(10): 1799-807.

[2]Helliwell T, Hider SL, Mallen CD. Polymyalgia rheumatica: diagnosis, prescribing, and monitoring in general practice. The British journal of general practice: the journal of the Royal College of General Practitioners 2013; 63(610): e361-6.

Acknowledgements

This study was endorsed by the international PMR/GCA study group.

Disclosure of Interests

Agnete Overgaard Donskov: None declared, Sarah Mackie: None declared, Ellen-Margrethe Hauge Speakers bureau: AbbVie, Sanofi, Sobi, MSD, UCB, Consultant of: AbbVie, Sanofi, Sobi, MSD, UCB, Grant/research support from: Novo Nordic Foundation, Danish Rheumatism Association, Danish Regions Medicine Grants, Roche, Novartis,Celgene, MSD, Pfizer, Roche, Sobi, CARLOS TORO GUTIÉRREZ: None declared, Andrea Hemmig: None declared, Aatke van der Maas: None declared, Berit Dalsgaard NIelsen Paid instructor for: Roche, Ib Hansen: None declared, Max Yates: None declared, Line Frølund: None declared, Karen Douglas: None declared, Kornelis van der Geest Speakers bureau: Roche, Elena Rezus: None declared, Sara Monti: None declared, Margarita Gromova: None declared, Vanessa Ocampo Speakers bureau: Abvie, Simone Appenzeller Speakers bureau: Janssen, UCB, Lilly and Pfizer, Mariama Erraoui: None declared, Adeola Ajibade: None declared, Andre Marun Lyrio: None declared, Rebecca Grainger: None declared, Maria Sandovici: None declared, Toby Helliwell: None declared, Elisabeth Brouwer Speakers bureau: Roche, Consultant of: Roche, Christian Dejaco Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, Consultant of: Abbvie, Eli Lilly, Janssen, Roche, Galapagos and Sanofi, Kresten Keller: None declared

OP0249 CHARACTERISTICS ASSOCIATED WITH POOR COVID-19 OUTCOMES IN PEOPLE WITH PSORIASIS AND SPONDYLOARTHRITIS: DATA FROM THE COVID-19 PsoProtect AND GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRIES

Background

Some factors associated with severe COVID-19 outcomes have been identified in patients with psoriasis (PsO) and inflammatory/autoimmune rheumatic diseases, namely older age, male sex, comorbidity burden, higher disease activity, and certain medications such as rituximab. However, information about specificities of patients with PsO, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), including disease modifying anti-rheumatic drugs (DMARDs) specifically licensed for these conditions, such as IL-17 inhibitors (IL-17i), IL-23/IL-12 + 23 inhibitors (IL-23/IL-12 + 23i), and apremilast, is lacking.

Objectives

To determine characteristics associated with severe COVID-19 outcomes in people with PsO, PsA and axSpA.

Methods

This study was a pooled analysis of data from two physician-reported registries: the Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection (PsoProtect), comprising patients with PsO/PsA, and the COVID-19 Global Rheumatology Alliance (GRA) registry, comprising patients with PsA/axSpA. Data from the beginning of the pandemic up to 25 October, 2021 were included. An ordinal severity outcome was defined as: 1) not hospitalised, 2) hospitalised without death, and 3) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics (age, sex, time period of infection), comorbidities (hypertension, other cardiovascular disease [CVD], chronic obstructive lung disease [COPD], asthma, other chronic lung disease, chronic kidney disease, cancer, smoking, obesity, diabetes mellitus [DM]), rheumatic/skin disease (PsO, PsA, axSpA), physician-reported disease activity, and medication exposure (methotrexate, leflunomide, sulfasalazine, TNFi, IL17i, IL-23/IL-12 + 23i, Janus kinase inhibitors (JAKi), apremilast, glucocorticoids [GC] and NSAIDs). Age-adjustment was performed employing four-knot restricted cubic splines. Country-adjustment was performed using random effects.

Results

A total of 5008 individuals with PsO (n=921), PsA (n=2263) and axSpA (n=1824) were included. Mean age was 50 years (SD 13.5) and 51.8% were male. Hospitalisation (without death) was observed in 14.6% of cases and 1.8% died. In the multivariable model, the following variables were associated with severe COVID-19 outcomes: older age (Figure 1), male sex (OR 1.53, 95%CI 1.29-1.82), CVD (hypertension alone: 1.26, 1.02-1.56; other CVD alone: 1.89, 1.22-2.94; vs no hypertension and no other CVD), COPD or asthma (1.75, 1.32-2.32), other lung disease (2.56, 1.66-3.97), chronic kidney disease (2.32, 1.50-3.59), obesity and DM (obesity alone: 1.36, 1.07-1.71; DM alone: 1.85, 1.39-2.47; obesity and DM: 1.89, 1.34-2.67; vs no obesity and no DM), higher disease activity and GC intake (remission/low disease activity and GC intake: 1.96, 1.36-2.82; moderate/severe disease activity and no GC intake: 1.35, 1.05-1.72; moderate/severe disease activity and GC intake 2.30, 1.41-3.74; vs remission/low disease activity and no GC intake). Conversely, the following variables were associated with less severe COVID-19 outcomes: time period after 15 June 2020 (16 June 2020-31 December 2020: 0.42, 0.34-0.51; 1 January 2021 onwards: 0.52, 0.41-0.67; vs time period until 15 June 2020), a diagnosis of PsO (without arthritis) (0.49, 0.37-0.65; vs PsA), and exposure to TNFi (0.58, 0.45-0.75; vs no DMARDs), IL17i (0.63, 0.45-0.88; vs no DMARDs), IL-23/IL-12 + 23i (0.68, 0.46-0.997; vs no DMARDs) and NSAIDs (0.77, 0.60-0.98; vs no NSAIDs).

Conclusion

More severe COVID-19 outcomes in PsO, PsA and axSpA are largely driven by demographic factors (age, sex), comorbidities, and active disease. None of the DMARDs typically used in PsO, PsA and axSpA, were associated with severe COVID-19 outcomes, including IL-17i, IL-23/IL-12 + 23i, JAKi and apremilast.

Acknowledgements

We thank all the contributors to the COVID-19 PsoProtect, GRA and EULAR Registries.

Disclosure of Interests

None declared

Recovery from aortic valve surgery: the trajectory of muscle mass, strength, and quality, and health-related quality of life (HRQoL)

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Barts Charity

OnBehalf

Queen Mary University of London (QMUL) and Barts Health NHS Trust

Background/Introduction:

The impact of intensive care unit-acquired weakness (ICUAW) is considerable and is associated with reduced physical function and impaired health-related quality of life (HRQoL). Patients’ undergoing elective cardiac surgery are known to lose significant muscle mass and strength in the first seven days after surgery, but little is known beyond that time. 

Purpose

We sought to investigate the effect of cardiac surgery on ICUAW (including muscle mass, strength, muscle quality) and HRQoL (including anxiety and depression and reintegration into society) until out-patient follow-up.

Methods

Eligible patients included adults undergoing a surgical elective aortic valve replacement without any pre-existing causes of severe muscle weakness or wasting. Muscle mass was measured using ultrasound of the rectus femoris cross-sectional area (RFcsa). Muscle quality was calculated using histogram analysis, specifically pixel intensity (PI), whereby a lower value is indicative of healthier muscle tissue. Muscle strength was measured using hand-held dynamometry specifically grip strength. HRQoL (EQ5D), anxiety and depression (hospital anxiety and depression scale (HADS)) and reintegration to normal living (RNLI index) were also collected. Measurements were assessed preoperatively, at day 7 and at out-patient follow-up.

Results

Thirty-one patients were recruited, with 22 (70.9%) patients attending follow-up. Patients lost 6.5% RFcsa (p= <0.0001) in the first seven days post-surgery and 10.1% (p = 0.0014) between preoperative assessment and follow-up. Hand-held grip strength decreased significantly (10.6%, p= <0.0001) in the first seven days post-surgery, however, differing to RFcsa, recovered considerably between day 7 and follow-up (7.7%, p = 0.018). Decreased muscle quality was observed solely in the first seven days after surgery (8.3%, p = 0.0094). The EQ5D visual analogue scale and crosswalk index increased significantly from preoperative assessment to follow-up (10%, p = 0.0250; 17.6%, p = 0.022 respectively) and day 7 to follow-up (11.7%, p = 0.0311; 27.9%, p = 0.011 respectively). While depression scores significantly decreased between the same time points as the EQ5D, changes in anxiety and RNLI scores, were non-significant.

Conclusion

Patients undergoing surgical aortic valve replacements lose considerable muscle mass in hospital, failing to recover even at out-patient follow-up. Furthermore, muscle quality decreases in the first seven days after surgery in line with the acute muscle loss. However, the impact on strength is less extensive as patients appear to recover the loss by follow-up. Patients’ health scores, function index and depression scores also improve, suggesting that muscle mass is the only outcome to not recover at follow-up. Therefore, patients appear to recover well from AVR surgery even surpassing some of their preoperative results, with the exception of the RFcsa.

Abstract 539: Utility of circulating tumor DNA in esophageal cancer: A potential prognostic biomarker in tumor staging, monitoring of treatment response and detection of recurrent disease

Background: Circulating tumor DNA (ctDNA) has clinical utility in monitoring treatment response and in the detection of disease recurrence in breast and colorectal cancer1,2. The aim of this study was to explore the role of ctDNA in the management of patients with esophageal cancer (EC).

Methods:Blood samples and tumor biopsies were collected from 79 patients after diagnosis of EC. In patients planned for surgery, blood samples were taken before and after neoadjuvant treatment, and during the surveillance period. Blood and biopsy tissue samples were analysed for mutations using a custom targeted amplicon-based approach to cover mutational foci across 9 of the most commonly mutated genes in EC.

Results:Somatic mutations in treatment-naïve EC tumor biopsies were detected in 71 out of 79 (90%) patients. Out of these 71 cases, 23 (32%) had detectable tumor-informed ctDNA in their plasma. The majority (90%) of patients who were ctDNA positive had either locally advanced or metastatic disease. For node negative locally advanced patients treated with curative intent, positive ctDNA status at diagnosis is a poor prognostic marker (HR 11.71; 1.16 - 118.80; p=0.037). In blood samples taken before and following neoadjuvant therapy (NAT), reversal of a ctDNA positive status after NAT was associated with an excellent response to treatment. In patients who had serial plasma samples taken during surveillance, detection of ctDNA was associated with inferior disease specific survival (HR 4.36; 1.07 - 17.88; p = 0.04).

Discussion:This study demonstrates that ctDNA may have clinical utility in the management of patients with EC by providing additional prognostic information at pre-treatment staging. In the absence of a widely accepted paradigm for surveillance after curative-intent treatment, assessment of ctDNA in post treatment blood samples may lead to the detection of early recurrent disease.

1. Dawson, S.-J. et al. Analysis of Circulating Tumor DNA to Monitor Metastatic Breast Cancer. New Engl J Medicine 368, 1199-1209 (2013).2. Tie, J. et al. Circulating tumor DNA analysis detects minimal residual disease and predicts recurrence in patients with stage II colon cancer. Sci Transl Med 8, 346ra92 (2016).

Citation Format: Carlos Suhady Cabalag, Michael Yates, Mariana B. Corrales, Paul Yeh, Stephen Q. Wong, Bonnie Zhang, Kenji M. Fujihara, Lynn Chong, Michael Hii, Sarah-Jane Dawson, Wayne A. Phillips, Cuong P. Duong, Nicholas J. Clemons. Utility of circulating tumor DNA in esophageal cancer: A potential prognostic biomarker in tumor staging, monitoring of treatment response and detection of recurrent disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 539.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey

BACKGROUND

Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments.

OBJECTIVES

We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation.

METHODS

Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model.

RESULTS

Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations.

CONCLUSIONS

Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.

POS0959 DIAGNOSTIC DELAY IN AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE NATIONAL EARLY INFLAMMATORY ARTHRITIS AUDIT

Background:

Diagnostic delay is a significant problem in axial spondyloarthritis (axSpA), and there is a growing body of evidence showing that delayed axSpA diagnosis is associated with worse clinical, humanistic and economic outcomes.1 International guidelines have been published to inform referral pathways and improve standards of care for patients with axSpA.2,3

Objectives:

To describe the sociodemographic and clinical characteristics of newly-referred patients with axSpA in England and Wales in the National Early Inflammatory Arthritis Audit (NEIAA), with rheumatoid arthritis (RA) and mechanical back pain (MBP) as comparators.

Methods:

The NEIAA captures data on all new patients over the age of 16 referred with suspected inflammatory arthritis to rheumatology departments in England and Wales.4 We describe baseline sociodemographic and clinical characteristics of axSpA patients (n=784) recruited to the NEIAA between May 2018 and March 2020, compared with RA (n=9,270) and MBP (n=370) during the same period.

Results:

Symptom duration prior to initial rheumatology assessment was significantly longer in axSpA than RA patients (p<0.001), and non-significantly longer in axSpA than MBP patients (p=0.062): 79.7% of axSpA patients had symptom durations of >6 months, compared to 33.7% of RA patients and 76.0% of MBP patients; 32.6% of axSpA patients had symptom durations of >5 years, compared to 3.5% of RA patients and 24.6% of MBP patients (Figure 1A). Following referral, median time to initial rheumatology assessment was longer for axSpA than RA patients (36 vs. 24 days; p<0.001), and similar to MBP patients (39 days; p=0.30). The proportion of axSpA patients assessed within 3 weeks of referral increased from 26.7% in May 2018 to 34.7% in March 2020; compared to an increase from 38.2% to 54.5% for RA patients (Figure 1B). A large majority of axSpA referrals originated from primary care (72.4%) or musculoskeletal triage services (14.1%), with relatively few referrals from gastroenterology (1.9%), ophthalmology (1.4%) or dermatology (0.4%).

Of the subset of patients with peripheral arthritis requiring EIA pathway follow-up, fewer axSpA than RA patients had disease education provided (77.5% vs. 97.8%; p<0.001), and RA patients reported a better understanding of their condition (p<0.001). HAQ-DI scores were lower at baseline in axSpA EIA patients than RA EIA patients (0.8 vs 1.1, respectively; p=0.004), whereas baseline Musculoskeletal Health Questionnaire (MSK-HQ) scores were similar (25 vs. 24, respectively; p=0.49). The burden of disease was substantial across the 14 domains comprising MSK-HQ in both axSpA and RA (Figure 1C).

Conclusion:

We have shown that diagnostic delay remains a major challenge in axSpA, despite improved disease understanding and updated referral guidelines. Patient education is an unmet need in axSpA, highlighting the need for specialist clinics. MSK-HQ scores demonstrated that the functional impact of axSpA is no less than for RA, whereas HAQ-DI may underrepresent disability in axSpA.

References:

[1]Yi E, Ahuja A, Rajput T, George AT, Park Y. Clinical, economic, and humanistic burden associated with delayed diagnosis of axial spondyloarthritis: a systematic review. Rheumatol Ther. 2020;7:65-87.

[2]NICE. Spondyloarthritis in over 16s: diagnosis and management. 2017.

[3]van der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-91.

[4]British Society for Rheumatology. National Early Inflammatory Arthritis Audit (NEIAA) Second Annual Report. 2021.

Acknowledgements:

The National Early Inflammatory Arthritis Audit is commissioned by the Healthcare Quality Improvement Partnership, funded by NHS England and Improvement, and the Welsh Government, and carried out by the British Society for Rheumatology, King’s College London and Net Solving.

Disclosure of Interests:

Mark Russell Grant/research support from: UCB, Pfizer, Fiona Coath: None declared, Mark Yates Grant/research support from: UCB, Abbvie, Katie Bechman: None declared, Sam Norton: None declared, James Galloway Grant/research support from: Abbvie, Celgene, Chugai, Gilead, Janssen, Lilly, Pfizer, Roche, UCB, Jo Ledingham: None declared, Raj Sengupta Grant/research support from: AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Karl Gaffney Grant/research support from: AbbVie, Biogen, Cellgene, Celltrion, Janssen, Lilly, Novartis, Pfizer, Roche, UCB.

POS1448 EVIDENCE BASED PRACTICE: WHAT IS THE EVIDENCE THAT BRITISH SOCIETY FOR RHEUMATOLOGY GUIDELINES ARE EVIDENCE BASED?

Background:

Clinical practice guidelines are designed to ensure that patients are treated according to best evidence, with the goal of optimizing clinical outcomes and reducing unwarranted variation in care. They compile, rate and translate the data available into recommendations that form the basis of evidence-based practice for most clinicians. Despite their importance, the evidence base informing different guidelines varies in quality. A recent study of American College of Rheumatology (ACR) Practice Guidelines demonstrated only 17 of 35 class I (strong benefit to harm ratio) recommendations were supported by level A evidence (high quality randomized controlled trails or meta-analyses)1.

Objectives:

To review the evidence supporting the British Society for Rheumatology (BSR) guidelines.

Methods:

Thirteen sets of guidelines that were available on the BSR website as of October 16th 2019 were reviewed (https://www.rheumatology.org.uk/practice-quality/guidelines). A range of methodologies (including Grading of Recommendations Assessment, Development and Evaluation (GRADE), Scottish Intercollegiate Guidelines Network (SIGN), EULAR and Royal College of Physicians (RCP) recommendations) were used to assess the quality of evidence and strength of recommendation. For comparability between guidelines the level of evidence was converted to a score between I (highest quality) and IV (lowest quality) and the strength of recommendation was converted to a rating between A and D. The polymyalgia rheumatica guideline was not assessed due to unclear methodology and lack of level of evidence for all recommendations.

Results:

Of the 12 BSR guidelines assessed, there were 554 recommendations in total. The number of recommendations per guideline ranged between 13 and 80. Across all assessed guidelines, 94 recommendations (17.0%) were classified as level I, 161 (29.1%) as level 2 and 299 (54.0%) as level 3 or 4. These figures are similar to those reported in the ACR guidelines (23%, 19% and 58% respectively)1. The proportion of level I evidence varied from 46.2% (Axial Spondyloarthropathy guideline) to 0% (Hot Swollen Joint guideline).

Conclusion:

Over half of all BSR guideline recommendations have level of supporting evidence of III/IV. A wide range of methodologies are used to generate BSR guidelines (GRADE, SIGN, RCP / EULAR). This makes it challenging for readers unfamiliar with these approaches to interpret evidence and hinders comparisons between guidelines. A standardized methodology for future guideline development would overcome these barriers.

References:

[1]Duarte-Garcia A, Zamore R & Wong JB. The Evidence Basis for the American College of Rheumatology Practice Guidelines. JAMA Intern Med, 2018 Jan 1;178(1):146-148.

Disclosure of Interests:

None declared

FRI0561 PRO-INFLAMMATORY DIETS ARE ASSOCIATED WITH INCREASED C-REACTIVE PROTEIN AND RHEUMATOID ARTHRITIS IN THE UK BIOBANK COHORT

Background:

Several individual dietary components have been associated with the risk of rheumatoid arthritis (RA) and recent studies have suggested that dietary indices, which account for the consumption of multiple foods, can be used as more complete measures of risk.

Objectives:

In this study we aimed to use the Dietary Inflammatory Index (DII), an independent index of dietary variable associated with inflammatory biomarkers, to evaluate potential associations between pro-inflammatory exposures in the diet, an inflammation biomarker (C-reactive protein) and RA onset using the UK Biobank cohort.

Methods:

The DII was calculated from data obtained in 24-hour dietary recall questionnaires collected on healthy participants on four separate occasions over an approximate annual period between Feb 2011 and April 2012. Cases of RA in the UK Biobank cohort were identified from the participants with appropriate ICD10 codes and compared against a randomly selected subsample of controls matched (20:1) for age, sex, smoking status and BMI.

Results:

Among the 502,519 subjects enrolled in Biobank, 141,769 had completed 24-hour dietary recall questionnaires and had full data for the 18 dietary variables that were required to create the DII (mean=0.03, range: -3.88, 4.22). Higher (positive) DII values indicate more pro-inflammatory diets. This index was positively correlated (p<0.001) with C-reactive protein (CRP), attesting to the validity of this index for assessing dietary inflammatory potential. A total of 1,423 participants were classified as having RA (1% prevalence in ‘dietary’ cohort of 141,769) according to their ICD10 codes that were last updated in 2018. Their mean age at enrolment (2006-10) was 59 years. There was a significant association between DII and RA: OR 1.05 [1.01-1.09]; p=0.028) that suggested RA cases were more likely to be consuming a pro-inflammatory diet.

Conclusion:

These data show a significant association between diet, inflammation (CRP) and RA in the UK Biobank population. The findings are consistent with a recent analysis of the US Nurse’s Health Study which was based on data only from females, indicating that these findings are likely to be robust and generalisable. Diet is one of the few modifiable factors that has the potential to reduce the risk of future RA onset. These results open the way to providing evidence-based health advice and for designing clinical interventions.

References:

[1] Shivappa N, Steck SE, Hurley TG, Hussey JR, Hebert JR. Designing and developing a literature-derived, population-based dietary inflammatory index. Public health nutrition 2014;17:1689-96.

Acknowledgments:

This research has been conducted using the UK Biobank Resource under Application Number ‘33557’

Disclosure of Interests:

None declared

THU0130 PATTERNS OF COGNITIVE DECLINE IN RHEUMATOID ARTHRITIS: RESULTS OF CASE CONTROL STUDY NESTED IN A POPULATION-BASED COHORT

Background:

The risk of cognitive decline and dementia is of particular interest for patients exposed to prolonged inflammation. In rheumatoid arthritis (RA), the inflammatory mechanisms that are central to the disease’s pathology share many features with those seen in Alzheimer’s disease (AD). However, published reports on the strength and direction of the putative associations with cognitive decline and dementia in RA are conflicting and the potential impact of immunomodulation has not been fully established. This study reports on a case control analysis comparing the results of a cognitive test conducted in RA cases from a longitudinal population register with healthy controls. The relationship between test outcomes, disease characteristics, and treatment is examined.

Objectives:

To characterise differences in cognitive function as assessed by a validated test battery between a group of patients with RA and a matched sample of healthy controls.

To investigate disease and treatment related factors that might have an impact on the cognitive function of patients with RA.

Methods:

A total of 38 people with RA were selected at random from subjects who had enrolled on the Norfolk Arthritis Register as part of the ICORA (Investigation of Cognition in RA) Study. The register is a large longitudinal inception cohort of patients recruited from both primary and secondary care. The study subjects were over 55 years old with a diagnosis of RA defined by the ACR criteria. Cognitive function was assessed using the Addenbrooke’s Cognitive Examination III (ACE-III) battery. The ACE-III is a validated screening test for dementia that evaluates five cognitive domains (attention, memory, verbal fluency, language and visuospatial skills). A cut off value of 82 is indicative of cognitive impairment. The ACE-III scores in the cases were compared with scores from 29 healthy population-based controls matched for age and sex.

Results:

The mean age of the patient and control groups was 69 years. The RA patients had a mean disease duration of 9.8 years and had been taking DMARDs for 7.1 years. Among the patient group with RA, 14 (37%) scored below 82 compared with none in the group of healthy controls. The mean ACE-III scores of both groups are shown in the table below:

Controls N=29RA N=38ACE-III Total95.2 (3.7)85.2 (7.4)•Attention17.7 (0.5)16.5 (1.9)•Memory24.6 (1.9)19.8 (4.0)•Fluency12 (1.4)9.9 (2.6)•Language25.5 (0.8)24.6 (1.7)•Visuospatial15.8 (0.5)14.4 (1.5)

After adjusting for age, sex, BMI and smoking status, significant differences were seen in the ACE-III total (adjusted mean difference(SE)=8.67(1.77); p<0.001), memory (adjusted mean difference(SE)=4.16(1.03); p<0.001), fluency (adjusted mean difference(SE)=2.29(0.67); p=0.001) and visuospatial (adjusted mean difference(SE)=1.36(0.38); p<0.001). There was no difference in attention (p=0.19) or language (p=0.10).

Among the patients with RA there was no clear association between disease duration and ACE-III Total scores; however, there was a trend for increasing cognitive scores in those who had been taking DMARDs for longer (<5 years: mean ACE-III Total=84.1; 5-10 years: 85.0: 11-14 years: 85.4; >14 years: 89.6).

Conclusion:

This study provides evidence to suggest that patients with established RA are at increased risk of cognitive decline when compared with healthy controls. The pattern of cognitive deficit, predominantly involving visuospatial and memory function, is consistent with an Alzheimer’s disease profile. Our data suggest a potential role for DMARDs in reducing the rate of cognitive decline in patients with RA.

Disclosure of Interests:

Tasuku Toyoda: None declared, Jacqueline Chipping: None declared, Jack Dainty: None declared, Stephen Jeffs: None declared, Michael Hornberger: None declared, Eneida Mioshi: None declared, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer, Max Yates: None declared, Alex MacGregor: None declared

FRI0198 OCULAR MORBIDITY IN PATIENTS WITH PMR AND GCA IN THE UK - A CPRD STUDY

Background:

Visual loss is the most serious consequences of a diagnosis of polymyalgia rheumatic (PMR) and giant cell arteritis (GCA). To date, information on the occurrence of eye disease in GCA has been based almost exclusively on small hospital-based patient series. Furthermore the lack of control group for these studies results in a lack of relative risk estimates for visual loss.

There are no accurate data on the prevalence and nature of eye complications among patients in the community. Patients with GCA may be exclusively managed in the primary care setting without referral for either temporal artery biopsy or ophthalmic department examination. Currently the incidence and prevalence of eye complications within this group are unknown.

Objectives:

Examine the absolute rate and relative risk of ocular morbidity, in a longitudinal community setting, in patients with PMR and or GCA including visual loss, AOIN including optic atrophy, cataract and glaucoma identified from Read codes in the (Clinical Practice Research Datalink) CPRD dataset.

Methods:

Construction of a disease cohort of incident diagnoses of PMR and GCA from patients in the CPRD matched to controls on age, sex (+/- 2 years) and practice location. Diagnosis were identified by CPRD researchers of those individuals between January 1997 to December 2015, with a minimum age at diagnosis of 50 years. Those with both a diagnosis of PMR and GCA were analysed in the GCA group. The outcomes of ocular morbidity included Read codes for severe visual impairment (multiple codes covered: blindness, severe visual impairment, registered partially sighted, issue of certificate of visual impairment, examination findings of 4/60 or worse), anterior ischaemic optic neuropathy (including codes of optic neuropathy and atrophy but not codes of glaucomatous atrophy), cataract, cataract extraction and glaucoma. Statistically modelling with Cox proportional hazards was used to generate hazard ratios for ocular morbidity taking account of censorship through death and moving out of area.

Results:

We identified 30,714 individuals with PMR (20,270 women; 66%) with a mean age at diagnosis of 72.9 year (sd 9.1) and 6,104 with GCA (4,309 women; 70.6%) with a mean age of 72.1 years (sd 9.4). Of those diagnosed with GCA 1,669 were also diagnosed with PMR. Using Read codes for severe visual impairment and blindness 5.9% of patients with GCA and 2.7% with PMR had this complication compared with 1.6% of the matched controls. The hazard ratio for the various ocular morbidities and by cases of PMR or GCA are shown in the table below:

Ocular morbidityPMR HR (95% CI) p valueGCA HR (95% CI) p valueSevere visual impairment1.76 (1.60, 1.94) p=<0.0013.55 (3.10, 4.08) p=<0.001Anterior ischaemic optic atrophy3.37 (2.15, 5.31) p=<0.00136.33 (25.19, 52.39) p=<0.001Cataract2.18 (2.04, 2.32) p=<0.0012.48 (2.22, 2.78) p=<0.001Cataract operation2.11 (1.97, 2.25) p=<0.0012.41 (2.13, 2.72) p=<0.001Glaucoma2.10 (1.91, 2.32) p=<0.0012.50 (2.10, 2.97) p=<0.001

Conclusion:

These community-based national data on risk of ocular morbidity in PMR and GCA show for the first time the risk of various ocular morbidities are increased for both groups. In addition this are the first estimates of relative risk compared to an age and sex matched population. These data are crucial for providing information to patients about their relative risk of ocular morbidity following a diagnosis of PMR or GCA.

Acknowledgments:

We would like to thank Dr Helen Strongman at the CPRD for carrying out patient searchers. We thank Dr Ferran Espuny Pujol for completion of the linkage request for dates of death.

Disclosure of Interests:

Max Yates: None declared, Allan Clark: None declared, Richard Watts: None declared, Alex MacGregor: None declared, Sarah Mackie Grant/research support from: Roche (attendance of EULAR 2019; co-applicant on research grant), Consultant of: Sanofi, Roche/Chugai (monies paid to my institution not to me)

Why governments cannot afford Codentify to support their track and trace solutions

BACKGROUND

In anticipation of the Protocol to Eliminate Illicit Trade in Tobacco Products (ITP) entering into force in 2018, there is a growing demand for information on track and trace (T&T) solutions for tobacco products. This article contrasts the efficacy of Codentify from the perspective of authentication with that of material-based multilayered security technologies.

METHOD

To calculate the probability of detecting one fraudulent pack under Codentify, we relied on a modified Bernoulli trial experiment with independent repeated sampling without replenishment. The probability is calculated using a multinomial distribution formula adjusted for the fact that both legitimate and non-legitimate packs may be sold in the market.

RESULTS

In a relatively small market, a law enforcement authority would have to inspect over 27 000 (almost 31 000) packs per week to have a 90% (95%) certainty that it did not miss a fraudulent pack under the Codentify system. A material based T&T solution would require only 45 (59) pack inspections a week to have the same level of confidence.

CONCLUSIONS

This study demonstrates the inefficiency of Codentify compared to other solutions that incorporate material-based security features. Signatories to the ITP should reject Codentify due to both its low efficacy and its clear violation of the ITP's requirement that T&T shall not be performed by or delegated to the tobacco industry or its front groups.

EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis

In this article, the 2009 European League Against Rheumatism (EULAR) recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) have been updated. The 2009 recommendations were on the management of primary small and medium vessel vasculitis. The 2015 update has been developed by an international task force representing EULAR, the European Renal Association and the European Vasculitis Society (EUVAS). The recommendations are based upon evidence from systematic literature reviews, as well as expert opinion where appropriate. The evidence presented was discussed and summarised by the experts in the course of a consensus-finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) determined. In addition to the voting by the task force members, the relevance of the recommendations was assessed by an online voting survey among members of EUVAS. Fifteen recommendations were developed, covering general aspects, such as attaining remission and the need for shared decision making between clinicians and patients. More specific items relate to starting immunosuppressive therapy in combination with glucocorticoids to induce remission, followed by a period of remission maintenance; for remission induction in life-threatening or organ-threatening AAV, cyclophosphamide and rituximab are considered to have similar efficacy; plasma exchange which is recommended, where licensed, in the setting of rapidly progressive renal failure or severe diffuse pulmonary haemorrhage. These recommendations are intended for use by healthcare professionals, doctors in specialist training, medical students, pharmaceutical industries and drug regulatory organisations.

Virtual reality gaming in the rehabilitation of the upper extremities post-stroke

BACKGROUND

Occurrences of strokes often result in unilateral upper limb dysfunction. Dysfunctions of this nature frequently persist and can present chronic limitations to activities of daily living.

METHODS

Research into applying virtual reality gaming systems to provide rehabilitation therapy have seen resurgence. Themes explored in stroke rehab for paretic limbs are action observation and imitation, versatility, intensity and repetition and preservation of gains. Fifteen articles were ultimately selected for review. The purpose of this literature review is to compare the various virtual reality gaming modalities in the current literature and ascertain their efficacy.

RESULTS

The literature supports the use of virtual reality gaming rehab therapy as equivalent to traditional therapies or as successful augmentation to those therapies. While some degree of rigor was displayed in the literature, small sample sizes, variation in study lengths and therapy durations and unequal controls reduce generalizability and comparability.

CONCLUSIONS

Future studies should incorporate larger sample sizes and post-intervention follow-up measures.

Responsible management of motor vehicle drivers with dementia

When Bridget Driscoll, a 44-year-old mother of two died after being struck by a motor vehicle, considered to be the first motor vehicle fatality in UK and possibly the world, the coroner stated 'I trust this sort of nonsense will never happen again'.1 Sadly, the coroner, medical practitioners and general public would be deeply and repeatedly disappointed. It was 1896. Motor vehicles were a curiosity. Drivers did not undergo any form of testing, be it medical fitness, driving ability or otherwise, and there were no licensing regulatory agencies. By 2010, road injury was the ninth most common cause of death globally (1.3 million deaths per annum) and dementia the fourth most common in high income countries.2 By 2030 the number of all licensed UK drivers who are 65 years or older will increase by almost 50% to almost one in every four drivers.3 If the juxtaposition of driving with dementia in an ageing population is not already a contentious social, political and medical issue, it certainly will become so.

Large outbreak of isoniazid-monoresistant tuberculosis in London, 1995 to 2006: case–control study and recommendations

Binary file ES_Abstracts_Final_ECDC.txt matches

Large outbreak of isoniazid-monoresistant tuberculosis in London, 1995 to 2006: case-control study and recommendations

We conducted a case–control study to examine risk factors for isoniazid-monoresistant Mycobacterium tuberculosis in an ongoing outbreak in London. Cases were defined as individuals with an isoniazid-monoresistant strain diagnosed from 1995 to the third quarter of 2006 with an indistinguishable restriction fragment length polymorphism (RFLP) or mycobacterial interspersed repetitive unit (MIRU)-variable number tandem repeats (VNTR) pattern who were resident in or had epidemiological links with London. Controls were all other individuals reported with tuberculosis to the Health Protection Agency London regional epidemiology unit or the HPA London TB Register during 2000 to 2005. Of 293 cases, 153 (52%) were sputum smear-positive compared with 3,266 (18%) of controls. Cases were more likely to be young adults (aged between 15 and 34 years), born in the United Kingdom (OR: 2.4; 95% CI: 1.7–3.4) and of white (OR: 2.9; 95% CI: 1.8–4.8) or black Caribbean (OR: 12.5; 95% CI: 7.7–20.4) ethnicity, a prisoner at the time of diagnosis (OR: 20.2; 95% CI: 6.7–60.6), unemployed (OR: 4.1; 95% CI: 3.0–5.6), or a drug dealer or sex worker (OR: 187.1; 95% CI: 28.4–1,232.3). A total of 113 (39%) of cases used drugs and 54 (18%) were homeless. Completion of treatment gradually improved in cases from 55% among those diagnosed up to the end of 2002 compared with 65% by the end of 2006. Treatment completion increased from 79% to 83% in controls from 2000 to 2005. There are complex social challenges facing many cases in this outbreak that need to be addressed if medical interventions are to be successful.

Seismic data from man-made impacts on the moon

Unusually long reverberations were recorded from two lunar impacts by a seismic station installed on the lunar surface by the Apollo 12 astronauts. Seismic data from these impacts suggest that the lunar mare in the region of the Apollo 12 landing site consists of material with very low seismic velocities near the surface, with velocity increasing with depth to 5 to 6 kilometers per second (for compressional waves) at a depth of 20 kilometers. Absorption of seismic waves in this structure is extremely low relative to typical continental crustal materials on earth. It is unlikely that a major boundary similar to the crustmantle interface on earth exists in the outer 20 kilometers of the moon. A combination of dispersion and scattering of surface waves probably explains the lunar seismic reverberation. Scattering of these waves implies the presence of heterogeneity within the outer zone of the mare on a scale of from several hundred meters (or less) to several kilometers. Seismic signals from 160 events of natural origin have been recorded during the first 7 months of operation of the Apollo 12 seismic station. At least 26 of the natural events are small moonquakes. Many of the natural events are thought to be meteoroid impacts.